MELBOURNE, Australia—Osteoporosis goes untreated in most men with fractures, and there are calls for more aggressive surveillance in male patients as well as a slightly different approach from that for diagnosing and treating osteoporosis in women, according to Peter R. Ebeling, MD.

In The New England Journal of Medicine, Dr. Ebeling writes, “One third of all hip fractures worldwide occur in men, and more men than women die in the year after a hip fracture, with a mortality rate in men of up to 37.5%.¹ Dr. Ebeling is from the department of medicine at Royal Melbourne Hospital/Western Hospital in Victoria, Australia.

He considers osteoporosis to be primary or idiopathic in up to 40% of cases in men. Bone loss in such patients accelerates after age 70, and rapid bone loss is common in men with deficient testosterone or estradiol levels. “In contrast to bone loss in women, who lose trabeculae with age, in men bone loss due to trabecular thinning is secondary to reduced bone formation,” Dr. Ebeling notes. Histopathologic studies also suggest that, because the average bone mineral density (BMD) in men who fracture is higher than in women, other factors such as microarchitecture or trauma may affect fracture risk more in men.

Dr. Ebeling recommends dual-energy X-ray absorptiometry measurement of BMD in all men >70 and in younger men who have clinical risk factors for osteoporosis. Another difference between current approaches to osteoporosis in men and women involves testosterone. He would also measure serum total testosterone and 25-hydroxyvitamin D. Patients with serum 25-hydroxyvitamin D levels <30 ng/mL (75 nmol/L) should be treated.

He says that in hypogonadal men aged >65 testosterone therapy increased spine BMD more than placebo, but that effects in eugonadal men are less clear. Other data suggest improved spinal BMD with testosterone therapy in men who had a testosterone levels <200 ng/dL. “The risks of testosterone therapy, which include polycythemia, sleep apnea, benign prostate enlargement, and possibly prostate cancer, argue against its use in eugonadal men with osteoporosis, until additional data are available to support this strategy,” Dr Ebeling writes.

If Z-scores are <-2, Dr. Ebeling recommends measurements of serum calcium and creatinine levels, liver function tests, thyrotropin level, and a complete blood count. Men with T-score of ≤-2.5 or who have had a vertebral fracture are candidates for oral bisphosphonates as first-line therapy.

High-intensity, progressive resistance training, weight-bearing exercise, or both increase BMD, although whether this translates into fewer fractures is unclear. Observational data suggest a lower fracture risk in older men who “maintain an active lifestyle.” Dr. Ebeling also notes that balance and strengthening exercise can reduce the risk of falls.

Timing of follow-up BMD testing is another area of uncertainty, but he suggests that testing at 2-year intervals “seems reasonable.”

Reference

1. Ebeling PR. Osteoporosis in men. N Engl J Med. 2008;358:1474-1482.